How To Respond To A Public Health Crisis
Time For Some Action
Back in early 1976, as President Gerald Ford was battling Ronald Reagan for the Republican nomination for President of the United States, a potential swine flu pandemic arrived in the U.S. It is, on some level, a lesson in both of the problems and concerns in the U.S. today: overreaction by the government and failure and ineptitude by the government. The pandemic didn’t actually materialize despite the fact that the government responded aggressively and quickly. Whether it was politically motivated or not, the Ford administration came across as competent and engaged and a look at how the various parts of government functioned reveals a much freer bureaucracy back then not beholden too much to an autocratic leader or the daily spins of the endless and almost needless media coverage we see today.
The affair began on Feb 4, 1976 when David Lewis, a U.S. Army recruit from Ashland Falls, MA, collapsed and died at Fort Dix, N.J. of what was soon determined to be — swine flu. Immediately, the Walter Reed Institute on Research tested 241 of their personnel at Fort Dix, most of them new recruits. Of those tested, “63 men” demonstrated “body response to swine influenza.” The men, it was believed, had been exposed to the virus through other soldiers.
Ultimately, samples from Lewis and some of the other men were sent to the Center for Disease Control in Atlanta, Ga, for identification. Dr. Walter R. Dowdle, one of the legends of the CDC’s work in the area of virology and diseases over the years, confirmed swine flu as the type of flu that infected several of the recruits and killed Lewis.
By February 12, just days after the death of Lewis, David Sencer, Director of the Center for Disease Control in Atlanta, “asked a number of officials from outside his agency to join him there for a full lab report on February 14.” This group included many individuals in the U.S. who worked on medical and epidemiology in the U.S. Dr. Harry Meyer, Director of the Bureau of Biologics was part of the meeting as was Dr. Harry Meyer, Director of the National Institute of Allergy and Infectious Disease.
The incident immediately set the administration of President Gerald Ford into quick motion. Swine flu had been the culprit in the deadly global flu pandemic of 1918–19, so there was little hesitation reacting to it. An unchecked pandemic could be quite destructive. Additionally, all indications at the time were that these were human to human transmissions meaning the flu strain could transfer from person to person contact just like the deadly strain in 1918.
Sencer next drafted a memorandum in two days for David Matthews, the then Secretary of the Department of Health, Education, and Welfare (HEW) shortly thereafter explaining the nation’s options. In the memorandum, Sencer called for nationwide immunization with the U.S. buying and testing the vaccine then distributing it to states for the execution of the immunization program.
Sencer broke a possible government response down to four choices: “do nothing,” “minimal response,” “government program,” and finally, a “combined approach,” which added a role for the private sector. Sencer stressed that with this strain “related antigenically to the 1918 flu…a decision had to be made within two weeks to give time for the preparation, testing, and administration of the vaccine before the next flu season.” A separate testing survey by the Army had concluded that perhaps 500 recruits had been exposed to the swine flu virus.
Sencer’s memorandum of action was said to be “deliberately designed to force a favourable response from a beset administration, which could not afford to turn it down and then have it leak.” Matthews received the memorandum on March 15 and by March 22, just a week later, a potential outbreak was the main topic of a cabinet meeting at the White House. All of this swift government action began according to Walter R. Dowdle without the CDC being able to confirm that the “virus would spread.” Yet, the evidence indicated there had been “human to human spread at Fort Dix” of a potentially deadly flu strain. And because there hadn’t been an outbreak of it in over 40 years, most of the population would be at risk, “especially young adults.”
At the White House cabinet meeting, James Lynn, Director of the Office of Management and Budget, set the agenda by writing that the meeting was “to discuss a possible Federal initiative to immunize all Americans against swine influenza.” Secretary Matthews was present at the meeting as was several other key government officials at the time, including the later Vice President Dick Cheney. Lynn presented several questions that needed to be answered: what was swine flu, what was the possibility of an occurrence of it in flu season 1976–77, and why is it believed that the strain identified in New Jersey could cause a pandemic? The reason for these very invasive questions was evidence of the seriousness of a possible pandemic but also the large amount of effort needed for a national immunization program.
In addition, at the March 22 cabinet meeting the various pros and cons and the four approaches presented by David Sencer were made available. This was quite important to any decision that would be made. Most interesting was the “no action” response to a potential pandemic. The private market would produce the amount of swine flu vaccine it thought would meet the demand was the key characteristic of this approach. A total effort by the government was presented as well. This option would involve the government handling the immunization on its own from start to finish. Assistant Secretary of HEW, Theodore Cooper eventually recommended the fourth approach for addressing the potential pandemic — a mixed approach involving government and the private sector working together.
By March 24, President Ford was fully aware of the potential pitfalls of an unchecked pandemic and had met with his aides and staff. He also met extensively with scientists and specifically spoke to Jonas Salk, the doctor who developed the polio vaccine. Salk, according to accounts, urged immunization. Ford even afforded an opportunity for dissent as he contemplated what the nation should do for the forthcoming flu season that would arrive in the Fall 1976. He agreed to meet privately with anyone attending the meetings who sought to express their opinion in private. Ford was aware of the Sencer memorandum spelling out in great detail the concerns of a pandemic and the pros and cons of each approach. At least one participant in the discussions considered Sencer’s memorandum as “a gun to our head.”
Oddly, Ford was not briefed on some very important issues related to an immunization program: “side effects from the vaccine, with children’s dosages, liability insurance, with expert opinion, with PHS public relations, and his own credibility.” These omissions would prove important to the program’s success and failure.
There was some notable dissent to the immunization program as well. The two main dissenters have not been lost to history either. One, Sidney Wolfe, of Ralph Nader’s Public Citizen, was not opposed to vaccination. Wolfe simply was opposed to using an untested vaccine on the public and did not believe swine flu vaccines had a strong track record. Wolfe had been a long-time critic of vaccines that provided only minimal benefit but endangered the health of those receiving them.
The biggest critic of the path Ford was taking was Dr. J. Anthony Morris. Morris worked at the Food and Drug Administration at the time in charge of vaccinations. He criticized the swine flu immunization decision asserting that there was no proof that flu vaccines were effective at all in preventing the flu. The decision to be so vocal cost Morris his job but he was able through legal action to get his job back later on. Needless to say, his dissent and that of Wolfe did not win the day.
Sencer’s fairly detailed memorandum and the threat and the human to human transmission of a swine flu strain gave President Ford little choice. He had to take the risk. Ford even said later that “you ought to gamble on the side of caution.” It was not a political decision according to Ford. Ford looked at the moment as “his own” and it was “his plain duty” to act. The only entity that could get 216 million people immunized was the White House, according to Ford. In that sense, Ford, without expressing it, meant, the government.
If It Was All So Simple
Ford announced on March 25, 1976 of a first of its kind national immunization program for swine flu.
“No one knows exactly how serious this threat could be. Nevertheless, we cannot afford to take a chance with the health of our nation,” Ford stated. He asked Congress for $135 million to fund the program. Two of the most famous developers of vaccines in history — Dr. Jonas Salk and Albert B. Sabin stood beside Ford as he made his statement. Most importantly, regardless of how anyone felt about Ford’s decision, it had been decisive and clear. As some evidence that Ford had gotten his point across, the Baltimore Sun wrote only days later that “to not launch” a national immunization program “could be very risky.” The Sun urged Congress to “quickly approve the plan.”
Congressional hearings almost immediately commenced on Ford’s request for $135 million for a national immunization program. On March 31, the House of Representatives held hearings that included testimony from many of the same players who had been tracking and researching the swine flu outbreak from Fort Dix appeared and testified.
Dr. Sencer was again a key to the hearings. Sencer testified that the virus they identified at the CDC was “similar to those we can best identify as characteristic of the 1918–19 strain.” Sencer also testified that after an extensive investigation that they could not determine how the virus entered the camp at Fort Dix.
It is notable to mention that while Congress was holding the hearings on the appropriations work on the vaccine was already in motion. By February 20, 1976, manufacturers had already been working hard on a vaccine and on March 1, 1976, a swine flu virus hybrid had been selected and was being used to create the vaccine.
Overall, during the Congressional hearings, witness after witness, most of whom were directly connected to the medical field or the field of public health testified in support of the immunization program. It had been far too long since the last outbreak of swine flu to risk leaving the public exposed to one of the world’s most deadly forms of influenza. The House approved the appropriations for the program on April 5; the Senate followed with its approval on April 9.
However, one of the key omissions from the early briefings with President Ford is already a major issue. The insurance liability issue (the government covering liability) is not part of the law and the Pharmaceutical Manufacturers Association (PMA) immediately sent a telegram to President Ford to express its displeasure. On March 31, representatives from PMA had testified before a congressional committee on the vaccination program. While the testimony is mostly technical in nature, it also again discusses the need for the government to address the liability issues associated with mass immunization programs. Without some intervention from the federal government, the issue would remain unresolved when the program began. The fact that the law that was passed did not address the issue left this issue unresolved.
By May 1, notices from “casualty insurers about cancellations of liability coverage for swine vaccine” had been received by all four producers of the vaccine. The manufacturers contacted the Ford administration four days later on May 5 and again pressed for indemnification “for all costs not directly tied to their own negligence in production.”
The liability issue would push on into the summer. However, work on the flu vaccine pushed forward as the various manufacturers would have been making flu vaccine anyway. The emergence of the swine flu strain just made it necessary to develop an additional strain to protect people.
On June 15, Spencer C. Johnson, President Ford’s Associate Director of Domestic Policy, received a telegram from E. Burke Giblin, Chairman of Warner-Lambert, one of the manufacturers of the vaccine. Giblin again stressed that the companies providing the vaccine had no insurance coverage going forward and they needed the government to step in and resolve this issue. Johnson assured Gilbin that legislation had been introduced to address this issue. It again demonstrated the critical nature of this issue. The manufacturers were being asked to produce a vaccine for 200 million Americans and had no insurance protection in case someone died or allegedly died from the immunization.
After a chaotic two month period that summer involving the manufacturers, representatives from the insurance companies, Congress, and members of the Ford administration, an insurance indemnification law finally passed on August 12, 1976, just before flu season. The bill would put the onus on the federal government to handle claims, if any, filed by individuals injured as a result of being immunized in the program. Regardless of how well the program would perform the government had accomplished its goal. It is notable to mention that there were early deaths in the immunization program, though none of the deaths were confirmed as attributable to the vaccine.
Looking back now, a small, yet potentially deadly swine flu strain had shown up in New Jersey in February 1976. On October 1, 1976, just eight months later, the government was ready to protect the entire public from the disease, if necessary. On October 14, 1976, in the White House, President Ford demonstrating his confidence in the project, received his swine flu vaccine on camera for the public to see. His great moment never materialized; the pandemic never showed, Jimmy Carter won the election in November, and the entire affair has been mostly forgotten except by scientists and public health officials.
The post mortem of President Ford’s immunization program provides some insight into government response to pandemics and why any response will never receive high votes of confidence. It also reveals how bad this administration has responded even giving it the benefit of some understanding that the current crisis is a lot different.
As for Ford’s performance and due to the fact that there was never a pandemic of swine flu, it now forever looks as if the Ford administration overreacted. Also, because a few major things did go wrong with the immunization, “the American public, and especially the press, became disenchanted” with the Ford administration. It was described in at least one circle as a ‘rank political boondoggle.’
But, the harsh treatment of the Ford administration is disingenuous especially from the press. The government identified a potential future danger to the wider public and made a quick decision to try to protect the citizenry. History insisted that Ford act and act decisively. A swine flu pandemic had come to the U.S. in 1918–19 and it had been catastrophic. He knew this and had been told this fact by his aides. President Ford also received a letter from a survivor of that pandemic in April 1976 and the survivor, Richard S.M. Mitchell, of Merritt Island, Florida, thanked Ford for his effort to protect him, and his family, from “the ravaging effects of swine flu.”
The swine flu vaccination program Ford implemented was the largest in history at the time which alone is impressive. Dr. Merrill J Snyder, of the University of Maryland Medical School, described that as a “feat in itself.” In addition, Dr. Harry Meyer, who was directly involved in the program from the start, describes the production of “two million doses of the vaccine” per week in the late summer, early fall, as a ‘stupendous industrial accomplishment.’ The vaccine was ready in six weeks rather than the customary four months.
Most importantly, the government responded to a possible dangerous and destructive pandemic that would have killed thousands and wrecked the economy and civic life if had occurred. President Ford was faced with a similar threat the Trump administration realized in November or December 2019 (depending upon what part of the information that is now available you accept). We are now aware that administration workers were assigned to the World Health Organization (WHO) when information regarding the pandemic came to light. WHO has repeatedly stated it provided the Trump administration with information in real time.
Trump also took actions that were bad themselves as opposed to not taking any action. One such action was disbanding the NSC pandemic unit. In addition, the revelation that the Trump administration was provided with a 69 page pandemic plan prepared by the outgoing National Security Council on what needed to be done to prepare for a pandemic is quite damaging. The plan was ignored. While the U.S. received its first case on January 20, 2020, the same day as South Korea, the two countries’ responses to the crisis were quite different. South Korea, to date, has less than 300 deaths; the U.S. has 80,000 and climbing steadily each day. With a now documented cavalier approach to a possible pandemic for three years, it was already too late once the coronavirus arrived in the U.S. in January 2020. The U.S. was not prepared and was in the crosshairs of a disaster that is still ongoing.
Of course, there are differences between the Ford response to a possible pandemic in 1976 and the Trump response so far in 2020. Ford knew flu season would end in March mostly and would not return until September. Influenza was also not new. It has been around for thousands of years. Swine flu, as well, had been around at least since 1918 when it killed millions around the world. Ford and everyone working with him had that advantage. While they would need to act fast, they had time to prepare a plan and even develop a vaccine.
The Trump administration had no such luxury; mistakes or a less than critical approach to a potential disaster would be catastrophic. The coronavirus strain was the potentially the modern equivalent of the swine flu of 1918. There was no natural immunity for anyone and no vaccine. Yet, as has been noted, a pandemic plan from NSC was provided to the Trump administration in 2017. There had been ample opportunity to prepare for a possible outbreak. The window of opportunity to prepare was from January 20, 2017 to the date the administration learned of a possible pandemic. When the first cases began appearing in the U.S., it was game, set, match, the virus was going to win big. It is also quite damaging that the Trump administration continued, even after being able to reassess their failed tactics, to pursue the chaotic path. The administration just keeps getting it wrong and now, four months into the pandemic, there is evidence itself that the White House might become a hot spot.
Dr. Anthony Fauci, the Director of the National Institute of Allergies and Infectious Diseases, currently, spoke in Washington D.C. on pandemics on January 10, 2017, just 10 days before Trump took office (his talk is still online). In his remarks, he stated that the next administration would be challenged like its predecessors by a pandemic. In fact, Dr. Fauci stated that “there would be a surprise outbreak.” This was yet another warning to the incoming administration to take the issue seriously. It is not known if anyone from the administration knew of Dr. Fauci’s lecture.
Looking back at the response of the Ford administration, 44 years later, it can be stated that Ford responded as a functioning government should respond despite the alleged political motive and despite the fact that the pandemic did not materialize. While it wound up that the response was to a pandemic that never occurred for whatever reason, the government and the state was ready to protect its people. Yet, it also should be pointed out that the effort to combat a potential pandemic was commenced with only a small degree of evidence. Is that the right way to proceed? Well, it depends upon your view of society. Right now, on the streets of the country there are protestors nearly every day calling for the economy to be re-opened. It forces other questions to surface: should the country have shut down? Are governors limiting the freedom of movement of people too much with their extensive shutdown orders?
And other deeper ideological questions of political and social value: does the U.S. have a society? Is there a social contract between the people and the state, mainly the federal government, for the government to protect its citizens? Or are you on your own? The comments of various political leaders have strongly suggested that the economy should be opened back up even if some have to die. The answer to that call is, okay, who is the first volunteer?
This brings me back to Gerald Ford and our original question — would Ford have gotten the response correct? Would he have already prepared for a potential outbreak by the time Covid-19 arrived in January 2020? Judging by his strong reaction to the swine flu threat, the answer is ‘Yes.’ What it would have looked like is hard to say? Maybe he ramps up vaccine preparation (coronavirus vaccine development had been dormant prior to the outbreak of this coronavirus) or maybe he does implement the Obama NSC playbook; regardless, it does appear Ford, as President, was a government man who understood the role of government which is lacking in the Republican Party these days and in government in general. He also, even with his flaws, and political instincts, understood that pandemics are almost always a lose-lose for government and yet, you have to respond. If you don’t, you would wind up like Trump is right now, a man with billboards going up blaming him for not doing his job and contributing to the death of over 44,000 people.
The Baltimore Sun
The Washington Post
The Swine Flu Affair, Richad E. Neustadt and Harvey V. Fineberg, M.D.
The Boston Globe
The Gerald Ford Presidential Archives
The Congressional Record